Provider Demographics
NPI:1104297605
Name:DOMB, JESSICA ELANA (NP)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:ELANA
Last Name:DOMB
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 ORAN PL
Mailing Address - Street 2:
Mailing Address - City:MORGANVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07751-2002
Mailing Address - Country:US
Mailing Address - Phone:917-443-7389
Mailing Address - Fax:
Practice Address - Street 1:480 RED HILL RD
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NJ
Practice Address - Zip Code:07748-3052
Practice Address - Country:US
Practice Address - Phone:848-225-6265
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-09
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY307222363LA2200X
NY341708363LF0000X
NJ26NJ00597800363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health